Gastroenterology Flashcards
what is the CLO test?
aka the rapid urease test
(CLO = cambylobacter like organism test)
used to diagnose H pylori - based on the ability of H pylori to produce urease which breaks Urea down to ammonia and CO2
a biopsy sample is mixed with urea and pH indicator - colour changes if urease is present
who should be screened for cirrhosis?
patients with
hep C infection
men drinking over 50 units and women drinking over 35 units of alcohol
alcohol related diseases
how is Wilsons disease diagnosed?
reduced serum copper
reduced caeruloplasmin
increased 24 hour urinary copper excretion
what is H pylori infection associated with?
peptic ulcer disease (95% duodenal and 75% gastric)gastric cancer B cell lymphoma of MALT tissue atrophic gastritis
where does diverticulosis most commonly occur?
sigmoid colon
barrets oesophagous increases the risk of which oesophageal cancer?
adenocarcinoma
what are adverse effects of metoclopramide?
extrapyramidal effects tardive dyskinesia hyperprolactinaemia parkinsonism
how is haemochromatosis treated?
venesection
when should a diagnosis of IBS be considered?
if the patient has any of the following for over 6 months:bloating
abdo pain
change in bowel habit
how is cirrhosis diagnosed?
transient elastography (fibroscan) uses a 50-MHz wave - passed from a small transducer on the end of an ultrasound probe. measures stiffness
how is endoscopically negative GORD treated?
1 month full dose PPI
if this works - 1 month low dose PPI
if this doesn’t work - H2RA drugs (ranitidine) or prokinetic
what are the features of a pharyngeal pouch?
dysphagia regurgitation aspiration neck bulge with gurgles on palpitation halitosis (bad breath)
what is Sister Mary Joseph’s node?
a palpable nodule in the umblicus due to metastatic cancer from abdo or pelvic region
what % of Crohns patients will have surgery?
80%
what is clostridium difficile?
a gram positive rod
often encountered in hospital
it releases an endotoxin which causes the syndrome: pseudomembranous colitis
it usually causes problems when broad spec antibiotics suppress the gut flora
what is peutz-jeghers syndrome and its characteristics?
autosomal dominant disease
characterised by hamartomatous polyps - in GI tract, mainly small bowel
pigmentation on lips, oral mucosa, face, soles and palms
intestinal obstruction e.g. intussusception
GI bleeding
50% die from GI cancer by 60
what is the MELD score?
Model for End stage Liver Disease
used more and more instead of Child Pugh score
calculates risk based on INR, creatinine and bilirubin
what are features of cyclical vomiting syndrome?
weight lossloss of appetite abdominal paindiarrhoea dizziness photophobia headaches
what is suspected in a young child who develops dysphagia who had a tracheo-oesophageal fistula repaired as a baby?
benign oesophageal stricture
what is the screening tool for malnutrition?
MUST Malnutrition Universal Screening Tool
what are uses of metoclopramide?
GORDgastroperesis (prokinetic action) in combo with analgesics
what prophylactic treatment is there for variceal haemorrhage?
propranolol
endoscopic band ligation - at 2 weekly intervals until all varices are gone
what is the max unit alcohol recommendation per week?
14 for both men and women - spread evenly over 3 days +
what imaging criteria is needed to diagnose toxic megacolon?
transverse colon >6cm
what are features of hepatic encephalopathy?
confusion, low GCS hand flap constructive apraxia triphasic slow waves on ECG raised ammonia
what are the red flags for gastric cancer?
new onset dyspepsia in person age >55 unexplained vomiting unexplained weight loss worsening dysphagia/odynophagia epigastric pain
how is Barretts managed?
high dose PPI
endoscopic surveillence every 3-5 years for metaplasia
if dysplasia - endescopic intervention is offered. including mucosal resection and radiofrequency ablation
which bacteria can cause fat malabsorption?
giardia lamblia
it is resistant to chlorine so can be transfered in swimming pools abroad
what is coeliac disease?
a sensitivity to the protein glutan leads to villous atrophy and malabsorption
what are classic features of globus pharyngis?
persistent sensation of having a lump in throat - when there is none
usually worse on swallowing saliva
symptoms are intermittent and relieved by swallowing food/drink
how is hepatic encephalopathy treated?
1st line = lactulose (promotes ammonia excretion and use by gut bacteria)
rifaximin = secondary prevention
what are features of autoimmune hepatitis?
signs of chronic liver disease amenorrhoea acute liver failure ANA/SMA/LKM1 antibodies raised IgG
what are the presenting features of haemochromotosis?
fatigue, erectile dysfunction arthralgia and arthiritis (mainly of hands) grey/bronze skin pigmentation liver: signs of chronic liver disease
diabetes
hypogonadism
what factors are considered in the modified glasgow score?
low oxygen increased age raised urealow calcium raised LDH/ASTlow albumin raised WBC - neutrophilia raised glucosethe acronym PANCREAS helps us to remember PaO2, Age, Neutrophilia, Calcium, Renal function - ura, Enzymes - LDH, AST, Albumin, Sugar
what are causes for increased ferritin without iron overload?
inflammation alcohol excess liver disease chronic kidney disease malignancy
what is the MoA of metoclopramide?
it is a D2 (dopaminergic) antagonist anti-emetic medication
what is Budd Chiari syndrome?
also known as
hepatic vein thrombosis
usually seen in the context of other haematological disease or procoagulant state
how do patients present with UC?
bloody diarrhoea lower left abdo pain tenesmus urgency extra intestinal features
what does vitamin B6 deficiency cause?
peripheral neuropathy
sideroblastic anaemia
what is systemic sclerosis?
an autoimmune disease affecting connective tissue.
can be localised or systemic
characterised by skin thickening due to collagen and small artery damage
how should endoscopic proven GORD be treated?
1-2 months full dose PPI
if this works - then low dose for 1 month
if this has no effect- double dose for 1 month
how is diarrhoea defined?
> 3 watery stools / day >14 days = chronic
what is mallory-weiss syndrome?
severe vomiting leads to painful mucosal lacerations at the gastro-oesophageal junction - causing haematemesis
how are UC flare ups classified?
mild <4 stools /day
moderate 4-6 stools/day
severe >6 stools/day signs of systemic disturbance
which medications are important to avoid in bowel obstruction?
pro-kinetics e.g. metaclopramide
may cause a perforation
what are complications of GORDs disease?
benign strictures Barretts anaemia ulcers oesophagitis carcinoma
how does Vitamin C deficiency present?
gingivitis, loose teeth
general malaise
gum bleeding, haematuria, epistaxis
poor wound healing
what are the diagnostic tests for haemochromatosis?
molecular genetic testing for C282Y and H63D
liver biopsy - Perls stain
what are features of Crohns disease?
non specific- lethargy and weight loss abdo pain diarrhoea (can be bloody) peri-anal disease - skin tags/ulcers extra intestinal features
a patient is found to have iron deficiency anaemia 10 days before surgery, what treatment should she be given?
IV iron (ferric carboxymaltose) 1g and repeated 1 week later (if not enough time or oral iron is not tolerated)
when is an UC flare up considered severe?
blood in stools or passing >6 stools/ day and 1 of the following: - HR >90 - anaemia - temp >37.8 - ESR > 30
what is the modified glasgow score for?
for scoring the severity of acute pancreatitis if 3+ factors are identified within 48 hours - it is severe
which surgical incision is used in an appendectomy?
Lanz (more cosmetic)
or Gridiron
what is the typical iron study profile in haemochromatosis patients?
transferrin saturation >50%
Raised ferritin and iron
low TIBC
what are the 3 types of colon cancer?
sporadic 95 %
HNPCC 5 %
FAP <1%
a parkinson patient develops GORD. which medication must he avoid?
metoclopramide
its a dopamine antagonist and may make parkinsonism worse
what will be the HepB serology for previous infection?
HbSAb +
Hb C Ab + (if naturally caught) or - (if vaccination)
HbsAg -
what is the most common type of inherited colon cancer?
HNPCC
what is haemobilia?
bleeding into the biliary tree
following connecting between splanchnic circulation and intra or extrahepatic biliary system
what are common causes of hepatomegaly?
cirrhosis
right heart failure
malignancy
how is a pyogenic liver abscess treated?
IV antibiotics and image-guided percutaneous drainage
amoxicillin, ciprofloxacin, metronidazole
what are adverse effects of PPIs?
can mask features of gastric cancer
can increase risk of fractures and osteoporosis by decreasing the absorption of magnesium and calcium
what is gallstone ileus?
small bowel obstruction secondary to gallstone impaction
vomiting, abdo pain and distention are seen
what is the most diagnostic test for suspected mesenteric ischaemia?
MR angiogram of the mesenteric vasculature
what are causes of liver cirrhosis?
viral hepatitis B + C
NAFLD
alcohol
what is the first line test for coeliac disease?
tissue transglutaminase antibodies
how are patients with upper GI bleed resuscitated?
- insert 2x large bore IV lines immediately
- platelet transfusion if platelets<50
- FFP if PTT >1.5x the normal
- crystalloid fluids to maintain systolic BP / packed RBCs if needed
- PPI if non variceal bleeding
once stable - all patients should have endoscopy (within 24 hours)
what is see on an abdo XR in gallstone ileus?
small bowel obstruction
and air in the biliary tree
which antibodies may be found in a patient with coelaic disease?
tissue transglutaminase Ab (IgA)
anti-endomyseal Abs (igA)
Anti-casein
how is faecal impaction treated?
high-dose macrogol laxatives
what is haemochromatosis?
autosomal recessive disease affecting iron absorption and metabolism (due to a mutation in the HFE gene)
what is the most appropriate test to check H pylori eradication?
Urea breath test
which diagnostic marker is tested to diagnose carcinoid syndrome?
5HIAA - from a 24 hour urinary collection
5 hydroxyindoleacetic acid
what test is recommended in women > 50 years with IBS symptoms?
serum CA 125
suspect ovarian cancer
IBS rarely presents in women this old
in suspected Gallstones, what is the best investigation?
abdominal ultrasound - this will enable us to see if there are gallstones or noturinary bilirubin, or ALT will just tell us generally if there is a cholestatic picture or not
how is a variceal haemorrhage treated?
stabilise/resucitate patient correct bleeding if needed - vit K, FFP vasoactive drugs - terlipressin prophylactic antibiotics - quinolones endoscopy - bind ligation Sengstaken -blakemore tube if uncontrolled haemorrhage
if all else fails, TIPS procedure
how does alcoholic ketoacidosis present?
metabolic acidosis
elevated serum ketones
normal or low glucose
elevated anion gap
what are symptoms of chronic mesenteric ischaemia?
episodes of severe, centreal, abdo painworse after eating (when bowel is working hard)arteriopath history - history of previous MI, hypercholesterolaemia, HTN etc.diarrhoea
which patients should be offered coeliac serological testing?
persistent unexplained abdo/gastro symptoms diagnosis of autoimmune thyroid disease or diabetes 1 faltering growth unexpected weight loss prolonged fatiguesevere/persistent mouth ulcers unexplained B12, folate or iron deficiencyIBS1st degree relative with coeliac
what are causes of chronic diarrhoea?
IBS ulcerative colitis Crohns disease coeliac disease colorectal cancer bile acid malabsorption pancreas disease
what is hepatorenal syndrome? (HRS)
rapid deterioration of kidneys in patients with cirrhosis or fulminant liver.
what are causes of acute liver failure?
alcohol
paracetamol
viral hepatitis A or B
acute fatty liver of pregnancy
what is CREST syndrome?
a limited sclerodoma Calcinosis (thickening of skin) Raynauds Eosphageal dysmobility Sclerodactyly (tighetning and hardening of toes/finger skin) Telangiectasia (spider veins on face)
how does a patient with faecal impaction present?
overflow diarrhoea may occurthis is suspected with a history of very liquidy diarrhoea and occasional incompetance along with the odd hard stool and abdo pain
Boerhaave syndrome
severe vomiting leading to oesophageal rupture
why do coeliac patients receive a pneumococcal vaccination?
they have functional hyposplenism
how is malnutrition defined?
BMI <18.5unintentional weight loss of 10% + in 3-6 months or BMI <20 with unintentional weight loss of 5%+ in 3-6 months
what are features of PSC?
cholestasis - pruritis and jaundice
fatigue
RUQ pain
ANCA (anti neutrophil cytoplasmic antibodies) positive and anti SM Abs
on ERCP - multiple strictures give beaded appearance
when is a positive diagnosis of IBS made?
if the patient has
1) abdo pain relieved by defecation or
2) abdo pain associated with change in bowel frequency/stool form and 2 of the following
1) altered stool passage (straining, urgency, incomplete evacuation)
2) bloating
3) made worse by eating
4) passage of mucus
how is dyspepsia treated?
1 month trial of full dose PPI
what is seen in UC on barium enema?
loss of haustrations
superficial ulcerations - pseudopolyps
long standing disease will causes long, narrow colon (drainpipe/lead-pipe)
what is pellagra?
vitamin B3 deficiency - niacin
what is carcinoid syndrome?
when metastases are present in the liver and release serotonin (so the serotonin avoids first pass metabolism in the liver)
how do you differentiate between alcoholic and diabetic ketoacidosis?
hypoglycaemia is associated with alcoholic
hyperglycaemic with diabetic
how is remission induced in a UC flare up?
- rectal aminosalicylates (5-ASA) or steroids. rectal mesalazine is superior
- oral aminosalicylates
- second line = oral prednisolone (wait 4 weeks before deciding aminosalicylate treatment hasn’t worked)
- IV steroids in severe collitis
what are the features of NAFLD?
usually asymptomatic
hepatomegaly
more ALT than AST
increased echogenecity on ultrasound
what is a possible complication of coeliac disease which may cause night sweats, fever, lymphadenopathy?
Enteropathy-associated T cell lymphoma
which surgical incision is used in a cholcystectomy?
Kocher’s
how do we investigate for NAFLD?
there is no indication for screening
it is usually an incidental finding - fatty changes on ultrasound
if fatty changes are picked up on US, NICE recommend ELF (enhance liver fibrosis) blood test to pick up any advanced fibrosis
what are risk factors for C dif infection?
broad/multiple antibiotics immunosuppression PPI long hospital stays GI tract surgery Inflam bowel disease
what are complications of Crohns disease?
fistulae, strictures, adhesions (inflammation through all layers of bowel wall)colorectal cancer small bowel canceroesteoporosis
how is haemobilia upper GI treated?
if it is a minor bleed - ensure patient is haemodynamically sstable and then no further treatment
if severe bleed - surgery needed . often a transcatheter hepatic artery embolisation to help prevent bleeding
if this doesnt work then surgical exploraiton and repair of the biliary tree may be indicated
what are the causes of pancreatitis?
GET SMASHEDGallstones Ethanol Trauma Steroids Mumps AutoimmuneScorpion venom Hypertriglycerides, hyprecalcaemia, hypothermia ERCPDrugs = mesalazine, bendroflumethiazide, furosamide, steroids, sodium valproate
which antibodies are present in the 3 different types of autoimmune hepatitis?
type 1 : Anti SM and Anti nuclear antibodies. seen in adults and children
type 2: liver/kidney microsomal type 1 antibodies (LKM1) - seen in children
type 3 - soluble liver-kidney antigen. seen in middle ages adults
what is the classic presentation for diverticulitis?
left iliac fossa pain and tenderness
anorexia, vomiting and nausea
diarrhoea
features of infection - pyrexia, raised WBC, raised CRP
what are features of budd chiari syndrome?
ascites
sudden onset, severe abdo pain
tender hepatomegaly
which inflammatory bowel disease is crypt abscesses most associated with?
ulcerative collitis
which 2 arteries does the TIPS (transjugular intrahepatic portosystemic shunt) procedure connect?
portal vein and hepatic vein
this aims to treat portal hypertension and does this by creating a shunt between the portal vein and hepatic vein, allowing the blood to bypass the liver
what are the 2 most common causes of lower abdo pain in young males?
appendicitis or testicular problems (torsion or infection)crucial to inspect scrotum to ensure not missing out the cause
what is the pathophysiology of HRS?
portal hypertension
leads to splanchnic vasodilation which then causes systemic vascular resistance
which means decreased effective circulatory volume
RAAS activated
causing renal vasoconstriction - and then HRS
and renal sodium avidity- and then ascites
what is acute acalculous cholecystitis? ACC
an inflammatory condition of the gall bladder - without involving gallstones or cystic duct obstruction = normal imaging
usually associated with a co-morbidity e.g. diabetes, shock, cardiac arrest
what is Wilson’s disease?
an autosomal recessive disease characterised by excessive copper deposit in tissues
which oesophageal cancer is associated with barretts?
adenocarcinoma
what is the connection between sushi consumption and cancer?
fish are high in nitrosamines which are carcinogens
what dietary advice should be given to IBS patients?
have regular meals, don’t miss meals
drink 8 cups a day
restrict intake of tea, coffee, alcohol, fizzy drinks
reduce high-fibre content
limit fresh fruit
reduce resistant starch
wind and bloating - increase intake of oats and linseed
what is the best primary care investigation to differentiate between IBS and IBD?
faecal calprotectin
what does a Crohns biopsy look like?
inflammation from mucosa to serosa
granulomatas
goblet cells
what is the best way to screen for harmful alcohol use and dependence?
AUDIT questionnaire
what is melanosis coli?
pigmentation of the bowel wallbiopsy shows pigment-laden macrophages it is associated with laxative abuse
what is primary sclerosing cholangitis?
disease with unknown aetiology
characteristics = fibrosis and inflammation of intra and extra hepatic bile ducts
what will a jeujunal biopsy in a coeliac patient show?
villous atrophy
crypt hyperplasia
increase in intraepithelial lymphocytes
lamina propria infiltration with lymphocytes
what do you suspect when an obese T2DM patient with deranged LFTs presents?
non alcoholic fatty liver disease
what is the Blatchford score?
a score used to assess and risk stratify patients with an Upper GI bleed it includes the following factors: Urea Hb Systolic BP pulse syncope melaena cardiac failure hepatic disease
what are investigation findings in Crohn’s disease?
raised inflammatory markers raised faecal calprotectin anaemia low Vit D and B12
how do you calculate No. of alcoholic units in a drink?
drink volume mL x % alcohol (ABV) /1000
what is the Waterlow score?
predicts risk of pressure sore
what are complications of primary biliary cholangitis?
malabsorption: osteomalacia, coagulopathy
sicca syndrome - occurs in 70% (dry mouth)
portal hypertension - variceal haemorrhage, ascites
hepatocellular carcinoma (20-fold increase)
what is the gold standard investigation for suspected oesophageal cancer?
endoscopy
how is H pylori treated?
PPI + amoxacillin + clarithromycin or
PPI + metronidazole + clarithromycin
what are features of oesophageal cancer?
weight loss dysphagia vomiting anorexia odynophagia, hoarsness, melaena, cough
what is intussusception?
when some intestine folds inside of itself- causing a blockage
what triad suggests liver failure?
encephalopathy (hand flap and confusion)
coagulopathy (raised prothrombin time)
Jaundice (raised bilirubin)
as well as hypoalbuminae
what are features of Whipples disease?
malabsorption - diarrhoea , weight loss large joint arthralgia skin - pigmentation and hyper-photosensitivity lymphadenopathy pleurisy and pericarditis rare - neurological symptoms
what is Whipple’s disease?
a rare multi-systemic disorder caused by tropheryma whippellii infection
jejunal biopsy shows deposition of macrophages containing PAS granules (periodic acid -schiff)
how is C dif diagnosed?
by detecting C Dif toxin in the stools (CDT)
what is a pharyngeal pouch?
it is a posteriomedial diverticulum through Killians Dehisence Killians Dehisence is a triangle in the wall of the pharynx between the cricopharyngeous and thyropharyngeous muscles
what are features of Wilson’s disease?
liver disease, neurological symptoms, corneal rings (ksyser fliesher rings), haemolysis, blue nails
what are side effects of mesalazine?
pancreatitis, GI upset, headaches, agranulocytosis, interstitial nephritis
when should a patient with ascites be given prophylaxis against SBP?
if the patients has had a previous episode of SBP
or
if the ascites has a protein <15 and a child pugh score <9 or hepatorenal syndrome
what triad points to mesenteric ischaemia?
history of CVDraised lactateacute abdo pain - tender but soft
what is the serum ascites albumin gradient used for?
it tells us if the ascites is due to portal hypertension or not
if the SAAG is > 11g/L = due to portal hypertension
Non alcoholic fatty liver disease covers a range of diseases, including…
steatosis
steatohepatitis (non alcoholic steatohepatitis - NASH)
progressive disease may go on to fibrosis and cirrhosis
what are complications of diverticulitis?
perforation
abscess formation
peritinitis
obstruction
what needs to be excluded in painless jaundice?
pancreatic cancer
how is the AUDIT questionnaire used?
its a 10 item questionnaire
max points = 40
a score >15 in men and >13 in women is likely to indicate alcohol dependence
AUDIT - C = abbreviated if little time
what should be administered to patients before an appendectomy ?
IV antibiotics
co-amoxiclav
what are the features of pellagra?
dermititis - classic sunburn rash dementia/dellusion diarrhoea
what is the ABG pattern seen in mesenteric ischaemia?
metabolic acidosis (raised lactate, low bicarbonate)
how is primary biliary cholangitis diagnosed?
anti mitochondrial antibodies M2 = seen in 98% patients anti SM antibodies seen in 30%raised IgM
how is a c dif infection treated?
1st line= oral metronidazole (10- 14 days)
2nd line =oral vancomycin
3rd line = oral vancomycin and IV metronidazole
what is an important side effect of Isoniazid? ( a Tb medication)
Vitamin B6 deficiency - causing peripheral neuropathy
usually prophylactic pyridoxine hydrochloride i prescribed alongside isoniazid
how do we maintain remission in Crohn’s patients?
azathioprine or mercaptopurine are first line
second line = methotrexate
mesalazine can be considered in patients with previous surgery
which antibiotic is now the leading cause of C dif?
3rd gen cephalosporins e.g. ceftriaxone
how is zollinger ellison syndrome diagnosed?
fasting gastrin levels
how does cyclical vomiting syndrome present?
severe nausea and sudden vomiting lasting for hours to days.prodromal intense sweating and nausea associated with migraine history
what are the 2 most common causes of upper GI bleed?
peptic ulcer disease or oesophageal varices
what are the features of zollinger ellison syndrome?
raised levels of gastrin usually due to a gastrin secreting tumour (in pancreas or duodenum) multiple peptic ulcers malabsorption diarrhoea 30% occur as part of MEN 1 syndrome
how does the urea breath test work?
the patient consumes a drink containing carbon 13 isotope
after 30 minutes, the patient exhales into a glass tube
mass spectrometry analyses the amount the C13 CO2
(suggesting presence of H pylori - urease)
shouldnt be performed within 4 weeks of antibacterials or 2 weeks of PPIs
what does the ELF (enhanced liver fibrosis) blood test actually test for?
hyaluronic acid
procollagen 3
tissue inhibitor of metalloproteinase 1
what is the MoA of loperamide?
loperamide slows down gut motility - its an anti-diarrhoeal it is a meu- opioid receptor agonist - in the submucosal neural plexus of the intestinal wall. this decreases peristalsis and therefore gastric motility
what is the most common cause of hepatocellular carcinoma?
world wide = chronic hepatitis B
in europe = chronic hepatitis C
the main risk factor is cirrhosis which is caused by the chronic hepatitis
what is Rovsing’s sign?
seen in apendicitis when palpating the LIF the patient feels pain in the RIF
how does oesophagitis present?
history of heart burn
painful swallowing - especially with bulky foods, retrosternal discomfort
systemically well
no weight loss
what is spontaneous bacterial peritonitis? SBP
a form of peritonitis usually seen in patients with ascites secondary to cirrhosis
clindamycin is associated with which bacterial infection?
c dif
what is the most prominent Crohns symptom in adults?
diarrhoea
which surgical incision is used in a caesarian section ?
Pfannenstials
transverse super pubic
what is plummer-vinson syndrome?
triad of dysphagia (secondary to oesophageal webs) glossitis, iron deficiency
what is associated with primary sclerosing cholangitis?
ulcerative colitis (80% of PSC patients have UC)
Crohns -less so
HIV
what are the features of primary biliary cholangitis?
middle aged womenpruritus lethargy LFTS: raise in ALP and gamma GT
how is Whipple’s disease treated?
year of antibiotics
co-trimoxazole best
how is cyclical vomiting syndrome managed?
avoidance of triggersprophylaxis: amitriptyline, propranolol and topiramate acute episodes: triptans, ondansetaron, prochlorperazinr
how may myasthenia gravis present?
dysphagia for both solids and liquids
weakness of extraoccular muscles (double vision)
ptosis
what is metabolic syndrome?
a combination of diabetes, hypertension, raised triglycerides, low HDL, abdominal obesity
what does the Hb C Antigen indicate?
infectivity
how does congestive hepatomegaly present?
persistent dull RUQ ache
with a history of heart failure
which antibodies are found in systemic lupus?
anti-dsDNA antibodies
although these can be present in normal individuals
with which IBD is primary sclerosing cholangitis most associated?
ulcerative colitis
what are extra-intestinal features of UC and CD?
arthirits episcleritiserythema nodosum osteoporosis
what is the most common type of OES cancer?
adenocarcinoma associated with GORDs/Barrets
how is IBS managed?
first line medication:
- diarrhoea = loperamide (anti-motility agent)
- constipation = laxatives e.g. sorbital/magnesium/bisacodyl/sennosides
(not lactulose) (second line laxative = linaclotide)
- pain = antispasmodics (dicyclomine, hyoscamine, buscopan)
second line = low dose TCAs e.g. 5-10mg amitriptyline
3rd line = eluxadoline
psychological and dietary advice
why can hoarsness be a sign of oesophageal cancer?
the cancer can interfere with the recurrent laryngeal nerve
according to ICD-10, when is a diagnosis of alcohol dependence made?
it the patient has 3 + of the following:
compulsion to drink
difficulty controlling alcohol consumption
physiological withdrawal
tolerant to alcohol
persistent use of alcohol despite harm
neglect of alternative activities outside of drinking
what is primary biliary cholangitis ?
a chronic liver disorder seen in middle aged women. intralobular biliary ducts become damaged by chronic inflammatory process which leads to cholestasis and eventually cirrhosis.
which vitamin, if taken in high doses, can be teratogenic?
vitamin A
what are features of carcinoid syndrome?
flushing (earliest symptom) diarrhoea palpitations hypotension bronchospasm right sided valvular stenosis if ACTH and GHRH are also secreted may present with other syndromes e.g. Cushings
which diabetic medication can cause cholestasis?
sulphonylureas e.g. gliclazide
in UC, which part of the bowel is most effected?
Rectum
what factors is the GCS based on ?
eye opening response verbal response motor response out of 15 <9 = major brain injury 9-12 = moderate
what is the most important diagnostic test for achalasia?
manometry showing excessive LOS tone which doesn’t relax on swallowingother tests include barium swallow and CXR
what is achalasia?
failure of oesophageal persitalsis and failure of relaxation of LOS due to degenerative losses of ganglia in the Auerbach’s plexus.
what are markers for excess alcohol consumption?
macrocytosis
raised gamma glutamyl transferase
how is Wilson’s disease treated?
penicillamine = first line. it chelates iron
trientine hydrochloride = alternative chelating agent
what cells point towards a gastric adenocarcinoma?
signet ring cells
when testing for tTG what condition must be met?
patient must have eaten gluten for 6 weeks before the test
which cancers are patients with HNPCC at risk of?
colon cancer - main
endometrial cancer - second
which upper GI symptoms require a 2 week urgent referal?
all patients with
dysphagia
upper abdo mass
weight loss AND pain, reflux or dyspepsia and >55years old
how is a patient with cirrhosis managed?
6 month ultrasound to check for hepatocellular carcinoma
endoscopy to check for oesophageal varices
how long should a c dif patient be isolated for?
48 hours
achalasia increases the risk of which oesophageal cancer?
squamous cell carcinoma
how does haemobilia present?
jaundice
upper GI bleeding
RUQ pain
(Quincke’s triad)
what is the most prominent Crohns symptom in children?
abdominal pain
how does viral hepatitis present?
history of travel abroad
RUQ pain, lethargy, nausea, anorexia
how is HRS managed?
vasopressin analogues e.g. terlipressin - causes splanchnic vasoconstriction
volume bulking with 20% albumin
or TIPS procedure
is an abdominal mass in RIF more likely to occur in Crohns or UC?
Crohns
what is Kantors string sign?
seen in Crohns disease
on a barium study
it is a long segment of narrowed terminal ileum - string like
what should primary care investigation for suspected IBS include?
ESR/CRPttG antibodies FBC
what are causes of acute diarrhoea?
gastroenteritis diverticulitis antibiotic therapy constipation causing overflow diarrhoea
which antibiotic should be given as a prophylactic treatment for SBP?
ciprofloxacin or norfloxacin
What is Child Pugh classification? what factors does it look at?
assesses the severity of liver cirrhosis it takes into account: bilirubin albumin prothrombin time encephalopathy ascites
what alcohol screening tools are there?
AUDIT
FAST
CAGE
what is the most common extra-intestinal feature of UC and CD?
arthritis
how do we induce remission in Crohns patients?
stop smoking
iv/oral steroids
enteral feeding with elemental diet
mesalazine - 2nd line to steroids
azathioprine or mercaptopurine may be used as an add on to induce remission. (not to be used as monotherapy)
methotrexate can be used in place of azathioprine
infliximab is useful in refractory disease or fistulating Crohns
metronidazole can be used for peri-anal disease
what is ferritin?
an intracellular protein that binds iron and releases it where it is needed
it is an acute phase reactent - so raises in inflammation
how is remission maintained in UC?
oral aminosalicylates (mesalazine) azathioprine and mercaptopurine
what are features of achalasia?
difficulty swallowing both solids and liquids Barium swallow shows: dilated oesophagus tapering off at the LOSheartburn regurgitation of food
how do we use the blatchford score?
score 0 = low risk, early discharge/outpatient treatment
score 6+ = 50% chance that the patient will need an intervention
what is a salpingectomy?
surgical removal of a fallopian tube
what are the features of Gilbert’s syndrome?
isolated hyperbilirubinaemia
an autosomal recessive disease of bilirubin conjugation due to a deficiency of UDP glucuronyl transferase
what histological changes occur in Barrett’s oesophagus?
metaplastic conversion of squamous epithelium of the oesophageous to columnar cells (similar to stomach)
what is the strongest risk factors for Barretts?
chronic GORD
how is Barretts Oesophagus managed?
depending on the staging
metaplasia = endoscopic surveillance
(< 3 cm - every 3-5 years)
(> 3 cm - every 2-3 years)
low grade dysplasia = 6 monthly surveillance/ endoscopic therapy (radiofreuency ablation/mucosal resection)
high grade dysplasia = endoscopic therapy
adenocarcinoma = surgery: oesophagectomy
what medication is presecribed for Barretts oesophagus?
20mg PPI daily
what are the main risk factors for oesophageal adenocarcimona?
GORD and Barretts.
seen in distal 1/3 of OES
developed world disease
most common oes. cancer in UK
what are the main risk factors of squamous cell carcimona (oesophageal)?
alcohol and smoking
proximal 2/3 OES
developing world disease
what are the tissue layers of the oesophagus?
epithelial cells basement membrane lamina propria muscularis mucosae submucosa muscularis propria adventitia
how is oesophageal cancer managed?
Carcinoma in situ/early T1 - endoscopic resection
T1, T2 NO = surgery
M1, T4 = palliative care
T3, N1 = chemoradiation, then re-evaluate for surgery
what do parietal cells produce??
intrinsic factor (absorbs B12) HCl
what do chief cells produce?
pepsinogen
chymosin/renin in neonates
what are symptoms of oesophageal candidis?
dysphagia
pain in tongue
odynophagia
how is oesopahgeal candidis treated?
fluconazole (-azole) = anti fungal
how does a duodenal ulcer present?
severe, pain radiating to back
relieved by eating
tarry stools
what are main causes for peptic ulcers?
H pylori - responsible for 90% duodenal ulcers
NSAIDs
what is the mechanism via which NSAIDs cause peptic ulcers?
- COX-1 inhibition; decreased prostaglandins; reduced mucosal protection and blood flow
- topical irritation
- COX -2 inhibitions; neutrophil adherence; mucosal injury
which risk factor is associated with gastric ulcers?
NSAIDs
which risk factor is associated with duodenal ulcers?
H pylori
give examples of histamine receptor blockers?
ranitidine
famotidine
cimetidine
how are peptic ulcers treated?
H pylori eradication therapy for those who test positive
stop NSAID use
8 weeks full dose PPI or H2RA
what are complications of peptic ulcers?
internal bleeding
perforation
gastric outlet obstruction
malignant transformation
what is the most common oesophageal disease in the UK?
GORD
what are symptoms of an acute upper GI bleed?
haematemesis
malena
hypovolaemia/syncope
abdominal pain
what are the common causes for an acute upper GI bleed?
- peptic ulcer disease
- erosions
- oesophagitis
- varices
what is the Rockall score used for?
used after endoscopy in acute GI bleed patients
scores prognosis/mortality
what are differentials for fresh blood in stools??
haemorrhoids irritable bowel disease acute anal fissure colo-rectal neoplasms acute proctitis
how are anal fissures treated?
- conservative; high fibre intake, high fluid intake, topical analgesia
- topical glyceral trinitrate, relaxes anus. may cause headaches
- diltiazem (CCB) = relazes anus
how are resistant anal fissures treated?
botox injections surgical sphincterotomy (risk of faecal incontinence)
how does colorectal cancer present?
abdo pain rectal bleeding weight loss change in bowel habit microcytic anaemia
what are the criteria for a suspected colorectal cancer referal?
unexplained iron deficiency anaemia
>6 weeks change in bowel habit and bleeding
right sided palpable mass/rectal mass
>60 years old and >6 weeks change in bowel habit
>60 years old and rectal bleeding (w/o anal symptoms)
what investigations are performed for suspected colorectal cancer?
colonoscopy/sigmoidoscopy
blood test for CEA (Carcinoembryonic antigen) - tumour marker for colorectal cancer
biopsy to confirm and stage tumour
who qualifies for colorectal screening?
patients aged 60-69
screen performed 2 yearly
based on faecal occult blood test
what is the sequence of carciogenic change of bowel epithelia?
normal epithelium - early adenoma - intermediate adenoma - late adenoma - carcinoma - metastasis
what mutation is present in FAP?
mutation in apc allele
what mutation causes Hereditary Non polyposis CRC?
mutation in the mix match gene - causing microsatellite instability
what is another name for HNPCC?
lynch syndrome
what is the amsterdam criteria ?
used in diagnosis of HNPCC
321 3 family member 2 generations 1 under 50 have coloractal cancer
which part of the colon does colorectal cancer occur most?
sigmoid
what is Duke’s classification?
staging of colorectal cancer
A- cancer in innermost lining and maybe muscle
B- cancer grown through the muscle lining
C - lymph node involvement
D - metastasis
what are the characteristic of an ileostomy?
spouted, usually in RIF, continueous liquid floq
what are the characteristics of a colostomy?
not spouted, LIF, solid periodic outflow
what is Hartmanns procedure?
a pathological segment is removed from the descending colon/ rectosigmoid colon and no anastomosis is made. instead the stump is brought through the abdominal wall and a colostomy formed
how does diverticulosis present?
recurrent LLQ pain, fever, bloating, constipation/diarrhoea
what investigation should be performed in suspected acute diverticulitis?
CT scan - to confirm suspicion and rule out complications
how is uncomplicated diverticulitis treated?
low residue diet
oral antibiotics (7-10 days) amoxacillin/clavulanic acid or
metronidazole + ciprofloxacin
which syndromes usually need a laparotomy ?
peritonitis
organ rupture
what are the Truelove and Witts criteria for assessing UC severity?
divided into mild, moderate and severe looks at the following factors: no. stools /day temp. CRP/ESR resting pulse Hb rectal bleeding
what are complications of UC?
toxic megacolon, with risk of perforation
VTE (all patients should be given prophylaxis)
hypokalaemia
increased risk of colonic cancer
how is remission induced in moderate UC?
rectal mesalazine (superior) or rectal steroids or oral mesalazine for more extensive disease 2nd line = oral prednisolone
how is remission induced in severe UC?
patient admitted
IV steroids, rectal steroids, VTE prophylaxis, re-hydration and electrolyte balance
rescue therapy with infliximab or ciclosporin - can avoid colectomy
when is a colectomy considered in UC?
if presenting with severe UC and patient hasn’t improved by day 7-10
urgent surgery
when is biologic therapy indicated in UC?
if immunomodulation (azathioprine) not tolerated or not working infliximab
how do we define IBD?
inappropriate immune response against gut flora in genetically susceptible individuals
what is Carnett’s sign ?
to determine whether abdominal pain is musculoskeletal or from internal viscera
patient should lie down and raise legs//head - if this exacerbates pain then =MS cause
what are bacterial causes of diarrhoea?
cambylobacter
C diff
shigella
salmonella
what are the different mechanisms of acute diarrhoea??
osmotic
secretary
mucosal inflammation
motility disturbance
what are important history questions for a patient presenting with infectious diarrhoea?
travel? employment? food consumption? animals? recent medication? swimming/drinking safe water supplies? contact with ill person? oral/anal sexual contact? HIV> immunosuppression? gastrectomy?
how is infectious diarrhoea managed?
rehydration
faecal testing
antibiotics if severe/systemic symptoms
what is the most common bacterial gastroenteritis?
campylobacter
what are features of a campylobacter infection??
food borne, faecal oral
reservoir = poultry, cattle, domestic animals
incubation period = 1-7 days
can cause GI ulceration
presents = diarrhoea, malaise, abdo pain. can become serious in 20% patients - pancreatitis, toxic megacolon, peritonitis, cholecystitis
how is campylobacter managed?
supportive
if severe - macrolide antibiotics e.g. erythromycin, clarithromycin
what are features of E coli infection?
there are subtypes:
enterotoxigenic - cholera like toxins, seen in travellers/children. food borne. incubation 12-72 hours
enterohaemorrhagic - profuse bloody diarrhoea, seen in all ages. cattle reservoir. shigella like toxins. incubation 12-60 hours
what are features of a salmonella infection?
common in raw eggs, reptiles
incubation: 12-72 hours
diarrhoea, vomiting and fever
food poisoning
what are features of shigella infection?
bacillary dysentery
1-8 days incubation
faecal/oral route - contaminated water/food
abdo cramps, bloody diarrhoea, etc
how can iatrogenesis lead to problems in IBS?
- invasive investigations - endoscopies, radiation
- unnecessary surgeries
- opiates
how is acute Hep B treated?
treatment usually unnecessary
avoid alcohol
immunise sexual contacts
patients with chronic infection, cirrhosis or HBV DNA >2000 for antivirals
when are anti viral medications indicated for Hep B infection?
chronic infection
cirrhosis
HBV DNA>2000
how is chronic HBV infection treated?
antivirals:
- .peginterferon alfa - 2a 48 weeks
- nucleotide analogues e.g. tenofovir or entecavir . needed long term but better tolerated
what % of Hep C infections become chronic?
75%
how do we test for chronic HCV?
test for HBV antibodies, if +ve…
do HCV PCR - looking for RNA to confirm active disease
then use elastography to test liver for cirrhosis
how is chronic HCV treate?
antivirals: PEG inteferon nucleotide analogue - ribavirin protease inhibitor ledipasvir, soforbuvir - non structural viral protein inhibitors
what are features of Hep E infection?
virtually identical to Hep A infection
may cause severe disease in pregnancy - high mortality. especially if infected in 2nd trimester
associated with pigs
v.rare in england
what are features of hepatitis delta?
it has incomplete RNA and so needs to co-infect with Hep B
can worsen the prognosis of Heb B
vaccination for Hep B also vaccinates against Hep Delta
treat with interferon alpha
what are symptoms of hepatitis?
may be asymptomatic
nausea, vomiting, malaise, raised temp, muscle and joint pain, dark urine, pale stools, jaundice, pruritis, abdo paina, exhaustion
what are the LFT levels in hepatitis?
raised bilirubin raised ALT>AST raised urea mildly prolonged PTT raised creatinine in fulminant liver failure
what is cholelithiasis?
presence of gall stones in gall bladder
presents as biliary colic - stones temporarily blocking the bile duct
what are gallstones made from?
90% are made of cholesterol
5-10% - pigmented
how does biliary colic present?
RUQ pain, radiating to shoulder
occurs for 30mins-hours, post prinadially
increases in intensity
what imaging should be done for biliary colic?
abdo ultrasound - pick up any gallstones and guide further imaging
if unremarkable, abdo CT to find alternative diagnosis
if stones in bile duct are suspected - decide between MRCP and intraoperative imaging
what is choleodolithiasis ?
gallstones in the common bile duct
what are the symptoms of choleodolithiasis?
RUQ pain, biliary colic, jaundice, pale stools
how is choleodolithiasis treated?`
treatment of choice is ERCP with sphinctnotomy and stone extraction to avoid complications e.g. acute (ascending) cholangitis or pancreatitis
what is cholangitis?
infection of the biliary tree - most commonly caused by obstruction from gallstones
what is charcot’s triad?
for diagnosing acute cholangitis
- RUQ pain
- fever
- jaundice
what imaging is down for suspected cholangitis?
abdo ultrasound - to detect a dilated common bile duct
if negative image then do a CT abdo with IV contrast
patients with history of biliary disease = consider early ERCP
what is the management for ascending cholangitis?
- broad spec antibiotics e.g. Pip/Taz
- rehydration
- electrolyte and coagulation therapy may be needed
- analgesia
- decompression with ERCP ( with or without sphinctenotomy) and stent insertion for drainage
what is cholecystitis?
acute gallbladder infection
usually due to an impacted gallstone in the cystic neck
how does cholecystitis present?
nausea, RUQ tenderness/palpable mass, positive murphey sign,
fever, pain lasting 3-6 hours, unremitting
how is cholecystitis treated?
Nil by mouth, antibiotics, analgesia, rehydration
grade severity
cholecystectomy - within 72 hours of symptom onset
2nd line = PCT percutaneous cholecystectomy tube inserted
how does pancreatitis present?
sudden intesne pain in epigastric region
radiates to back
nasuea and vomiting
fever and tachycardia
pain worse on moving, alleviated in fetal position
what are important blood test results in pacreatitis?
raised amylase/lipase (> 3 x the upper limit)
what investigations should be performed for suspected pancreatitis?
ultrasound - if suspected biliary disease cause
CT - best for staging pancreatitis and looking for complications
MRCP used more for serial examinations
how is acute pancreatitis managed?
NPO, rehydration, analgesia + anti-emetics
monitor ABGs, blood glucose, oxygen levels closely
identify electrolyte imbalances and correct
treat based on aetiology.
- if gallstones = cholecystectomy or ERCP with sphincterotomy
- if alcohol = lorazepam and vitamin replacement
how does chronic pancreatitis present?
dull aching epigastric pain, radiating to back. worse ~30 mins after a meal.
associated with heavy alcohol consumption
jaundice (10%)
diabetes and glucose intolerance
steatorrhea
malnutrition
initial tests for suspected chronic pancreatitis?
amylase, glucose
abdo XR - look for calcifications
if negative - pancreas protocol CT
how is chronic pancreatitis managed?
- analgesia
- pancreatic enzymes - pancreatin, Creon
- smoking and alcohol cessation
- omeprazole (PPI) - reduce enzyme deactivation in the lumen
- dietary modification/enteral feeding
if still unbearable - surgical intervention. resection - pancreaticoduodenectomy. (whipple procedure)
what is a whipple’s procedure?
pancreaticoduodenetomy
removal of the pancreatic head, gallbladder and bile duct
how do we grade hepatic encephalopathy?
1) altered mood/behaviour. poor sleep, poor arithmetic, dyspraxia
2) drowsiness, confusion, slurred speech, liver flap, personality change
3) stupor, incoherent, restless, liver flap
4) coma
how does liver failure lead to cerebral oedema?
ammonia waste builds up. in the brain this waste is cleared by astrocytes in a process involving glutamate. glutamine builds up and causes an osmotic imbalance - and shift of fluid.
how is cirrhosis defined?
irreversible liver damage
loss of normal hepatic architecture with bridging fibrosis and nodular regeneration
what does loss of function of the liver lead to?
jaundice
decreased hormone metabolism (raised oestrogen)
decreased drug metabolism
decreased immunity, so increased risk of sepsis
coagulopathy
what does portal hypertension cause?
varices ascites caput medusa splenomegaly renal failure piles encephalopathy
